Uncomplicated Illness Research Articles

33 Use of CHU Ste. Justine online resources prior to visiting the Emergency Department for less-urgent, acute febrile illness

Abstract Background Over the past 20 years, visits to paediatric emergency departments (EDs) across Canada have steadily increased, with a higher proportion of presentations for lower acuity symptoms. Many paediatric institutions’ websites now provide information and recommendations for caregivers on common illnesses and reasons for seeing healthcare providers or going to the ED. Increasing the use of internet resources may improve health literacy and hopefully decrease ED use for lower acuity presentations like uncomplicated viral illness. Objectives The objective of this study was to assess whether caregivers presenting with children with lower acuity at triage were aware of and using the online resources provided by our paediatric institution to help with at-home management of febrile illnesses and to guide their decision to present to the ED. Design/Methods This was a cross-sectional study in a tertiary care university-affiliated paediatric ED in an urban setting. Participants were a convenience sample of caregivers of children 6 months to 17 years old with a fever 72 hours or less and triaged low acuity (Canadian Triage and Acuity Scale levels 3 to 5). Caregivers of children with underlying significant systemic illness were excluded. Consenting participants completed two questionnaires. The first questionnaire included demographic data, information on baseline internet utilisation, use of general online health information and our institutions’ website specifically, and whether use of those resources influenced their decision to present to the ED. After browsing dedicated web materials developed by our institution (“Before going to the emergency room” and “Fever”), questionnaire 2 asked for feedback on the website. Results From April to July 2023, 100 caregivers participated in the study (response rates questionnaires 1 and 2: 80% and 70%, respectively) (Table 1). Half (49%) of caregivers researched their child’s symptoms prior to coming to the ED (Table 2). Approximately one third (39%) of respondents were aware that our institution provided online information for caregivers about common symptoms and when to present to the ED. Half (51%) of caregivers who completed questionnaire 2 said they would not have come to the ED if they had read these resources prior (Table 3). Many (66%) respondents reported they would be “likely/very likely” to look up their child’s symptoms on the institutional website before going to the ED in the future. Conclusion Half of caregivers presenting to the ED for their child’s lower-acuity febrile illness conducted research on their child’s symptoms prior to visiting the ED and most were influenced in their decision to come to ED by what they found. Most caregivers were not aware that our institution had online resources available. Promotion of the institutional resources available to parents may empower parents to manage common symptoms at home and prevent ED visits for lower-acuity illness.

Medical Decision-Making: Close-Up on Problems Addressed

This article includes answers to commonly asked questions about the number and complexity of problems addressed as an element of medical decision-making (MDM). This includes the following: Acute uncomplicated illness versus acute illness with systemic symptoms Conditions managed by other physicians or other qualified health care professionals (QHPs) Addressing multiple acute uncomplicated illnesses or injuries Documenting chronic conditions Social determinants of health (SDOH) as diagnoses

Study of serum ferritin levels in various phases of dengue in pediatric dengue patients admitted in a tertiary hospital

Background: Dengue is a cause of public health concern with case fatality rate of 1%. Ferritin is an acute-phase reactant which is produced in response to infection and inflammation. The aim of this study is to evaluate serum ferritin levels in various phases of dengue in pediatric dengue patients. Methods: A hospital-based, prospective, and observational study was done involving 30 dengue cases diagnosed by positive NS1 antigen or dengue specific serology (capture enzyme-linked immunosorbent assay). Serum ferritin was estimated by electrochemiluminescence in all three phases of dengue. Clinical and platelet count monitoring was done daily; respectively. All children classified as dengue with or without warning signs and severe dengue according to the World Health Organization guidelines on diagnosis treatment, prevention, and control of dengue, 2009. Results: Out of total of 30 children with mean age of the children were 7 years, and 61% were male who were majority. High serum ferritin levels were noted during critical phase. Eight children with dengue shock syndrome and one with acute respiratory distress syndrome were managed in intensive care unit as compared to non-severe dengue with statistically significant difference as p<0.05. Increase in serum ferritin is associated with severe thrombocytopenia. The mean hospital stay duration was found to be 5±3 days (mean ± standard deviation). Conclusion: Serum ferritin levels taken on admission can serve as a reliable and cost-effective biomarker in the assessment and in predicting the severity of dengue fever. Serum ferritin levels may help in identifying an uncomplicated dengue illness, from that of patients who may require inpatient admission/intensive critical care.

Clinical manifestations and outcome of Mpox infection in Qatar: An observational study during the 2022 outbreak

Mpox emerged in May 2022 as a global outbreak, mostly in hitherto non-endemic countries. To describe the epidemiological and clinical characteristics of mpox in Qatar, data were retrospectively retrieved for all laboratory-confirmed mpox cases diagnosed in Qatar between May and November 2022. Twelve cases were identified; of which 10 were males, and the median age was 33.5 years (IQR 24.5–37.5). Recent sexual exposure was reported in 9 patients, 6 of which were outside Qatar. Seven individuals reported exclusive heterosexual contact. Pleomorphic skin lesions were present in all cases, with anogenital involvement in 11. Fever (7/12) and lymphadenopathy (4/12) were relatively common. All cases were HIV-negative. The majority of cases had an uncomplicated and self-limiting clinical illness. In conclusion, the majority of early mpox infections in Qatar were purportedly acquired through heterosexual contact, primarily among middle-aged men. The clinical course was mostly uneventful. In the absence of active case finding and the mild and self-limiting nature of the clinical illness, undetected community transmission cannot be ruled out.

Synthesis and Meta-analysis of 3 Randomized Trials Conducted in Burkina Faso, Ghana, and Uganda Comparing the Effects of Point-of-Care Tests and Diagnostic Algorithms Versus Routine Care on Antibiotic Prescriptions and Clinical Outcomes in Ambulatory Patients

This meta-analysis included 3 randomized trials conducted in sub-Saharan Africa comparing the effects of point-of-care tests and diagnostic algorithms versus routine care on antibiotic prescriptions and clinical outcomes in ambulatory patients presenting at outpatient facilities with acute uncomplicated febrile illness.

Laporan Kasus : Acute Respiratory Distress Syndrome (ARDS) pada Pasien Post COVID-19 dengan Fibrosis

. The Coronavirus Disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus (SARS- CoV2) has led to a pandemic situation. According to the WHO classification, COVID-19 patients could be classified with severity as uncomplicated illness, mild pneumonia, severe pneumonia, acute respiratory distress syndrome (ARDS), sepsis and septic shock.Case illustration: A 25 year old female, with a chief complaint of shortness of breath and cough, history of cesarean section surgery with indications of severe preeclampsia and hysterectomy for uterine atony. weeks previously the patient was confirmed positive for COVID-19 without symptoms and tested negative through the Polymerase Chain Reaction (PCR) follow up examination. The Chest X-Ray showed the right lung atelectasis, bronchitis and minimal pleural effusion. CT scan of the chest showed a ground glass opacity in almost all bilateral lung segments with septal thickening in according with the picture of COVID pneumonia with cardiomegaly. The patient was intubated and put on a ventilator due to acute respiratory failure and the drugs include antiviral (oseltamivir), chloroquine, antibiotic (meropenem) and steroid (methylprednisolon) intravenous.Discussion: Post COVID-19 fibrosis is one of the emerging complications of COVID 19 pneumonia and ARDS. This case report highlights ARDS in patient with Pulmonary Post Covid-19 and its challenges in diagnosis and treatment. The combination treatment of mechanical ventilation and drugs such as antiviral,chloroquine, antibiotic, steroid intravenous could give the good outcome for the patient of ARDS due to Pulmonary Fibrosis Post COVID - 19

The NP's role in increasing RVU values.

The NP's role in increasing RVU values.

Economic Burdens of Uncomplicated Malaria in Primary Health Care (PHC) Facilities of Plateau State, Nigeria: Patients' Perspectives.

This study aims at evaluating the costs incurred by patients in Primary Healthcare facilities of Plateau State, Nigeria, due to uncomplicated malaria management. Patients' information on resources used and absence from the labour market due to uncomplicated malaria illness were collected using the self-reported cost of illness instruments across 24 selected Primary Health Care (PHC) facilities in Plateau State. The collated data were used to estimate the direct medical and non-medical costs incurred by patients through the summation of the various costs paid out of pocket for the services; while the indirect cost was estimated using the human capital theory. All analyses were conducted through Microsoft Excel and IBM Statistical Package for Social Sciences (SPSS®) version 23 software. The average direct cost per episode of uncomplicated malaria was estimated at NGN 2808.37/USD 7.39, while the indirect average money equivalence of the time lost due to the ailment was estimated at NGN 2717/USD 7.55, giving an average cost of treating uncomplicated malaria borne by patients in Plateau State per episode to be NGN 5525.37/USD 14.94. The projected annual cost of the disease was NGN 9, 921,671,307.22 (USD 27, 560,198.08). The study showed substantial financial costs borne by patients due to uncomplicated malaria in Plateau State, comprising 50.83% of direct cost and 49.17% of the indirect cost of medications.

Secondary Hemophagocytic Lymphohistiocytosis In Typhoid Fever: Case Report

Background: In poor countries, typhoid fever is a major cause of fever. The illness can vary in severity from an uncomplicated febrile illness to sepsis and complications like hemophagocytic lymphohistiocytosis (HLH), which affects multiple organs. A delay in diagnosis is frequently the biggest obstacle to a good outcome due to the rarity of this syndrome. Case: A 38-year-old male was admitted with complaints of persistent intermittent fever for three weeks. Other complaints were maculopapular rashes, epistaxis, black-colored stools, abdominal pain, nausea, vomiting, fatigue, and decreased appetite. He was transferred to our hospital due to progressive clinical deterioration. On physical examination, he was pale, with a temperature was 39.5C, a dry tongue with petechial spots at the root of the tongue, and some maculopapular rash of the entire body. There was splenomegaly. Laboratory investigations showed pancytopenia. IgM salmonella typhi was positive. A liver function test revealed transaminitis. Additional laboratory tests showed hypertriglyceridemia, hyperferritinemia and hyponatremia. USG’s abdomen showed splenomegaly. Patient possibility of secondary HLH was considered and investigated accordingly. He was given packed red blood cells, platelets transfusion, and a high dose of methylprednisolone orally. He showed dramatic improvement, complete blood count (CBC) normalized on day 7 with complete recovery on follow-up. Conclusion: We report a hemophagocytic lymphohistiocytosis in typhoid fever with persistent intermittent fever. Based on our case, early diagnosis and prompt treatment are critical to a successful patient’s recovery.

Pulmonary Manifestations of Dengue Fever Section at a Tertiary Care Centre in Northern India: A Cross-sectional Study

Introduction: Dengue Fever (DF) is associated with systemic inflammation, clinically manifesting as involvement of different organ systems, including the pulmonary system. Pulmonary involvement is characterised by pleural effusion, pneumonia, haemoptysis, pulmonary haemorrhage, secondary bacterial infections with Acute Respiratory Distress Syndrome (ARDS), and Dengue Haemorrhagic Shock Syndrome (DHSS), which are the leading causes of mortality and morbidity. Aim: This study aims to analyse the pleuropulmonary manifestations associated with DF. Materials and Methods: This cross-sectional study was conducted at a tertiary care centre in northern India from June 2018 to November 2018. A total of 140 patients diagnosed with DF using Non-Structural protein 1 (NS1), Immunoglobulin (Ig)M, (Ig)G rapid card tests and confirmed by Enzyme-Linked Immunosorbent Assay (ELISA) were included. Patients were examined for pleuropulmonary manifestations and other systemic features. Baseline investigations, including Complete Blood Count (CBC), Haematocrit (Hct), Liver Function Test (LFT), Renal Function Test (RFT), chest X-ray (PA view), and HighResolution Computed Tomography (HRCT) of the chest when required, were performed. Data analysis was carried out by using Statistical Package for Social Sciences (SPSS) version 25.0. Results: A total of 140 patients (108 males and 32 females) aged between 18 and 35 years were included and analysed. Among them, 113 (81%) were diagnosed with uncomplicated febrile illness, 17 (12%) with Dengue Haemorrhagic Fever (DHF), and 10 (7%) as Dengue Shock Syndrome (DSS). Patients with co-morbidities, particularly respiratory system illnesses, and young patients were found to be at increased risk of morbidity. Pleuropulmonary manifestations observed in the study included pleural effusion, pneumonia, pulmonary haemorrhage, ARDS, and pneumothorax. Conclusion: DF is associated with the involvement of the pulmonary system, and its incidence is increased in cases of moderate to severe disease. Therefore, pleuropulmonary manifestations can be useful in evaluating the severity of DF cases.

Ten years of nurse consultation at the pediatric emergency department

The Nurse consultation (CI) was implemented in 2013 at the emergency department of the Lausanne Children's Hospital. It offers medical delegated care for children aged three to 18. Ten years after its implementation, this article takes stock of its progress. Patients and families are satisfied with the care provided at a rate of 94.3 %. The CI seems to offer quality and safe healthcare. It allows the emergency team to have more time and resources for patients whose lives are at risk or need careful assessment due to their age or medical history. The CI is an innovative and relevant model of care in the context of uncomplicated childhood illnesses.

The Impact of Active Screening and Management on COVID-19 in Plateau Region of Sichuan, China.

BackgroundIn December 2019, the cases of pneumonia of unknown etiology emerged in Wuhan, China, and rapidly spread throughout the country. The disease was later designated by the World Health Organization (WHO) as Coronavirus Disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS CoV-2). Few studies have assessed the clinical characteristics of COVID-19 and control strategies used to mitigate disease spread in high-altitude plateau regions of China.Study ObjectiveTo assess the impact of real-world strategies to control COVID-19 spread in remote plateau regions.MethodsA retrospective study was performed to assess the epidemiology of COVID-19 and strategies used to control disease spread in the high-altitude plateau of Sichuan, China from 24 January 2020 to 19 March 2020.ResultsCOVID-19 spread and outbreaks in Sichuan were attributed to mass gatherings. A total of 70 patients and 20 asymptomatic individuals were found in the hypoxic plateau region of Sichuan. Twelve patients were admitted after the onset of symptoms, while 58 patients and 20 asymptomatic individuals were found by active screening. The symptomatic patients included those with uncomplicated illness (16/70, 22.9%), mild pneumonia (44/70, 62.9%), and severe pneumonia (10/70, 14.3%). Most patients in the study area showed relatively mild and atypical symptoms such as low or no fever and dyspnea. The incidence of severe pneumonia, fever, dyspnea, and interstitial abnormalities identified by chest CT were all significantly lower in screened patients than those admitted after symptom onset (P < 0.05). Severe pneumonia was noted in patients with chronic conditions like hypertension, diabetes etc. as compared to less severe pneumonia in healthy subjects (P <0.05). No patients died and all were eventually discharged.ConclusionMass gatherings increased risk of spread of SARS-CoV-2 responsible for COVID-19. Active screening and early management have collectively contributed to reduced incidence of severe pneumonia and satisfactory prognoses of infections with COVID-19 in this hypoxic plateau region.

Retrospective analysis of disease profile and percentage of COVID positivity among patients presenting to paediatric triage of a tertiary care hospital during COVID pandemic lockdown period

Background: Currently, limited reports analyze pediatric patients infected with SARS-Covid-19. We conducted this study with the purpose of assessing the disease profile and percentage of COVID positivity among pediatric patients presenting to our triage area.Methods: A retrospective quantitative observational study was conducted in the pediatric triage area, department of pediatrics, Civil hospital campus, Ahmedabad, India. Patients aged 0-12 years were included with the study period from 1stApril to 30th June, 2020. Patients fulfilling the ICMR testing criteria were considered as suspected COVID patients and tested for COVID. Remaining patients were triaged and managed either on OPD basis or admitted in PICU, NICU or pediatric ward. Also, data of OPD attendance rate and immunization rates of 3 months (April, May and June) of 2019 and 2020 were collected from pediatric OPD and vaccination center.Results: A total of 709 patients presented in the triage out of which 35.5% were neonates, 28.6% were between 1-12 month, 23.2%were between 1-5 years and 12.6% were between 5-12 years. 12 out of 97 suspected patients tested positive for COVID 19. Among COVID positive patients, 50% had uncomplicated illness or mild pneumonia, while 50 % had critical illness and were admitted in COVID ICU. Mortality among non COVID patients was 22.7%, and among COVID patients was 16.6%. A sharp fall was noted in the OPD attendance (10 times) and immunization rates (3 times) this year compared to last year.Conclusions: Incidence of COVID positivity was comparable to the studies done in other countries. Even during the pandemic peak, the major chunk of pediatric admissions still belonged to the non COVID conditions. The drastic fall in immunization rates can have implications in the form of re-emergence of vaccine preventable diseases in the coming times.

Systemic Lupus Erythematosus and Coronavirus Disease 2019.

Coronavirus disease 2019 (COVID-19) is a contagious infectious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It manifests with variable clinical pictures ranging from asymptomatic to mild or uncomplicated illness to severe disease with possible multi-organ involvement, with respiratory and vascular systems being the most often affected. Since COVID-19 can affect patients with autoimmune rheumatic conditions, the concomitant presence of two diseases may have clinical characteristics whose knowledge may help facilitate clinical management. This review discusses the data available in the literature on COVID-19 in systemic lupus erythematosus (SLE) patients.

Therapeutic Modalities in the Management of COVID-19: A Worldwide Landscape

Several strains of the novel Coronavirus have been identified and countries around the world are conducting research to identify, map and compare each type. Its infection can manifest with symptoms ranging from uncomplicated non-specific illness to a more damaging syndrome that include mild to moderate pneumonia (Covid-19 pneumonia broadly categorised into the phenotypes: L-type and H-type); Acute Respiratory Distress Syndrome; Sepsis and Septic shock. Although, this virus has a low mortality rate, the danger lies in its virulence and transmission dynamics.

Anti Pyretic and Analgesic activity of Herbal Formulation: I mplications in managing COVID-19 Fever

Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, that was first recognized in Wuhan, China, in December 2019. Genetic sequencing of the virus suggests that it is a beta coronavirus closely linked to the SARS virus. While most people with COVID-19 develop the only mild or uncomplicated illness, approximately 14% develop a severe disease that requires hospitalization and oxygen support, and 5% require admission to an intensive care unit. In severe cases, COVID-19 can be complicated by acute respiratory distress syndrome (ARDS), sepsis and septic shock, multi organ failure, including acute kidney injury and cardiac injury. Reports of the pattern of Covid symptoms suggest that mild fever, cold and cough are the most common symptoms on an average by 5 days after exposure to the virus. Given the current SARS-CoV-2 (COVID-19) pandemic, the availability of reliable information for clinicians and patients is paramount. There have been a number of reports stating that non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids may exacerbate symptoms in COVID-19 patients. There is enough literature to prove that many molecules from plants have shown important therapeutic activity with lesser side effects as compared to conventional medicines. Therefore, the present study is aimed to evaluate Plant extracts of proven antiviral activity, which are described as antipyretics and analgesics in classical Ayurvedic texts for their analgesic &amp; antipyretic effect in laboratory animals. Tab. Febcin formulation was selected.

A Surge in Pediatric Coronavirus Disease 2019 Cases: The Experience of Texas Children's Hospital From March to June 2020.

BackgroundAn understanding of the clinical characteristics of children with coronavirus disease 2019 in diverse communities is needed to optimize the response of healthcare providers during this pandemic.MethodsWe performed a retrospective review of all children presenting to the Texas Children’s Hospital system with testing for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from March 10, 2020 through June 28, 2020.Demographics were recorded for all patients undergoing testing and clinical characteristics and outcomes were recorded for children with positive tests.ResultsOf 16,554 unique patients ≤ 21 years of age who were tested for SARS-CoV-2, 1215 (7.3%) patients tested positive. Infants under 1 year of age and patients aged 18-21 years had the highest percent of positive tests at 9.9% (230/2329) and 10.7% (79/739), respectively. Hispanic children accounted for 66% (802/1215) of positive tests, though they only represented 42.1% (6972/16554) of all children tested for SARS-CoV-2. Of the 1215 children with a positive test, 55.7% had fever, 40.9% had cough, 39.8% had congestion or rhinorrhea, 21.9% had gastrointestinal complaints, and 15.9% were asymptomatic. Only 97 (8%) patients were hospitalized (of which 68% were Hispanic). Most hospitalized patients had underlying medical conditions (62/97, 63.9%), including obesity. Thirty-one hospitalized patients (31/97, 32%) required respiratory support and nine patients (9/97, 9.3%) received SARS-CoV-2 antiviral therapy. Two patients died.ConclusionsA relatively high percentage of Hispanic children tested positive for SARS-CoV-2 and were hospitalized. Most children with detection of SARS-CoV-2 had uncomplicated illness courses, some children were critically ill, and two patients died.

New onset status epilepticus in influenza associated encephalopathy: The presenting manifestation of genetic generalized epilepsy.

We hereby present a case of a young woman with no history of seizures or epilepsy who experienced a de novo generalized Non Convulsive Status Epilepticus (NCSE) followed by encephalopathy lasting for several days during influenza B infection. Influenza can have a broad spectrum of presentation ranging from an uncomplicated illness to many serious conditions as is the case of influenza associated encephalitis/encephalopathy (IAE). In this context however, it is possible to observe seizures and/or status epilepticus as the presenting manifestation of a genetic generalized epilepsy.

Management of COVID-19 in Children and Adolescents -A Practical Up-to Date Guideline

Sufficient high-quality data are unavailable to describe the management approach and guideline of COVID-19 disease in pediatric and adolescent population which may be due to mild presentation in most of cases and less severe complications than older ages.&#x0D; World Health Organization was concerned with the establishment of an approved guideline to manage the increasing number of COVID-19 patients worldwide aiming to prevent or lessen COVID-19 global burden.&#x0D; The clinical features have a wide spectrum starting from uncomplicated mild illness, mild-moderate pneumonia, severe pneumonia, acute respiratory distress syndrome, sepsis, septic shock, and multisystem inflammatory syndrome in children.&#x0D; Many important definitions were developed to identify the COVID-19 case status including confirmed, suspected, and probable case.&#x0D; Many laboratory tests may be beneficially done but reverse transcriptase – polymerase chain reaction (RT-PCR) for SARS-CoV-2 RNA is diagnostic.&#x0D; Patient isolation and adequate intake of fluid and calories, antipyretics (preferably paracetamol), antibiotics (in secondary bacterial infections), and bed rest are the mainstay of approved supportive treatment. While oxygen supplementation may be added in moderate to severe cases; anticoagulation prophylaxis (enoxaparin) is strongly advised in children with certain situations where hypercoagulability state is identified, and therapy should be evaluated based on risk factors.&#x0D; New approaches, drugs, and therapies are currently under research to manage COVID-19 pediatric and adolescent patients including antivirals (lopinavir/ritonavir, and favipiravir), remdesivir, tocilizumab, dexamethasone, convalescent plasma, and specific treatment of multisystem inflammatory syndrome in children (immunoglobulin, steroids, tocilizumab, anakinra, and aspirin).&#x0D; The practical approach was summarized in a flow chart scheme to assist health care professionals to manage COVID-19 in children and adolescents within a rapid look though details are given in the text.

A study of treatment preference for diarrhea among Tengger people in Pasuruan, East Java, Indonesia

PurposeThis study aims to describe the treatment preference, especially in relation to traditional medicine, modern health care and a combination of both, in diarrheal cases among the Tengger ethnic minority group.Design/methodology/approachA cross-sectional survey was conducted in all eight villages of Tosari District, Pasuruan Regency, East Java Province. Tengger people were major resident in the area for generations. Convenience sampling and a face-validated structured questionnaire were used to recruit and face-to-face interview 377 Tengger people.FindingsThe study found that modern health care was the dominant preference (52%, n = 196) selected by Tengger people when they have an episode of diarrhea, compared to traditional medicines and mixed approach. Most respondents opted to visit one facility or to stay at home (64.3%, n = 242). Statistical significant relationships were found between treatment choice and age (p &lt; 0.001), sex (p &lt; 0.001), religion (p = 0.011), distance (p &lt; 0.001), educational background (p &lt; 0.001) and job (p &lt; 0.001). A clear pattern between treatment choice and age was revealed with younger groups tended to choose modern health care, while older groups more preferred the traditional approach.Practical implicationsThis work could provide an insight that when the young Tengger people are having uncomplicated and common health illness, such as diarrhea, they tend to use modern treatment approach.Originality/valueThis study fulfilled an identified need to explore the trend of treatment approach across generations in the Tengger society as a model of the minor ethnic group in Indonesia.